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Treatment involves repletion of potassium through the oral and/or intravenous routes trusted viagra capsules 100mg. Treatment with intravenous magnesium is often necessary to fully correct the hypokalemia buy cheap viagra capsules on line, although the serum magnesium may be normal (serum magnesium represents only 1% to 2% of total body magnesium such that a patient may be magnesium depleted yet have a normal serum value) discount 100mg viagra capsules overnight delivery. Hyperkalemia Hyperkalemia can be arrhythmogenic and at high levels can be rapidly fatal. The merging of the T and U waves makes distinguishing and measuring them more difficult. Sodium bicarbonate (three ampules [150 mEq] added to 1 L of a 5% dextrose solution) can also shift potassium into cells, but should be used when there is concurrent metabolic acidosis. In addition, the resultant volume overload may be poorly tolerated in patients with end-stage renal failure. Longer-term treatment to rid the body of excessive potassium includes Kayexalate (25 to 50 g in 100 mL of 20% sorbitol given orally). Dialysis should be reserved for hyperkalemia that is unresponsive to these treatments. When hyperkalemia is a consideration, such rhythms should not be mistaken for, and should not be treated as, ventricular tachycardia. These findings in a patient with a known malignancy, such as lung cancer, strongly suggest the presence of hypercalcemia. Chapter 10 Athletes and Arrhythmias Athletes with arrhythmias constitute a potentially high-risk group that may need special attention and evaluation in addition to care that might be required for nonathletes, especially if these athletes have symptoms. Some athletes with arrhythmias require restriction of their athletic activities or at least aggressive therapy due to their underlying heart problems and/or their arrhythmias, but others can return to full activity if the arrhythmia is corrected (e. Athletes are different from nonathletes because of their high visibility; their drive, which can push them beyond normal physiologic stresses; specific physiologic stresses that result in major changes in the sympathetic/parasympathetic innervation of the heart and vasculature; metabolic changes such as hypokalemia, hyponatremia, acidosis, and other electrolyte abnormalities; and alterations in carbon dioxide and oxygen saturation. There can be fluctuations in body temperature and other physical and psychological influences. There can be changes in circulating mediators such as angiotensin-converting enzymes, steroids, serotonin, and histamine. In addition, during sports activities, there can be extreme changes in heat and cold exposure, further stressing the physiologic milieu. The type of exercise (static, dynamic, anaerobic, or aerobic) may have a significant impact on the outcome for that individual. Arrhythmias can start with extreme initial stress, during prolonged activity, and sometimes at abrupt termination of activity. It can be difficult to determine if heart disease is present or if cardiac abnormalities represent adaptation to exercise; for example, increased left ventricular wall thickness may be due to “athlete’s heart,” and deconditioning might reverse the effects. Furthermore, there can be bradycardia and other arrhythmias that are typical for a highly trained athlete. The most common sports in which sudden death tends to occur are basketball, football, track, soccer, and swimming. There are now new recommendations and guidelines on eligibility for competitive athletics and sports based on underlying cardiovascular conditions. Additionally, there have been revisions in evaluation, management, and restriction of athletes at risk for arrhythmias. Evaluation of the athlete with palpitations or syncope is a challenge because athletes tend to have conditions that do not necessarily lend themselves to easy testing and testing tends to have a low sensitivity and specificity. The electrocardiogram is often abnormal in trained athletes and therefore is not predictive of development of arrhythmias. Early repolarization is a notch on the down stroke of the R wave and is actually a prominent J wave (Fig. Restriction is in order for patients with hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy, and Brugada syndrome. Many individuals have symptoms that might appear to be arrhythmic in origin but are not. Many arrhythmias may be of prognostic importance but are not easily diagnosed by symptoms alone. It is not uncommon for individuals to be completely asymptomatic during serious and potentially life-threatening arrhythmias; therefore, proper selection of monitoring techniques is crucial to secure the rhythm diagnosis and develop a management strategy. There have been important advancements in the technology for monitoring arrhythmias. The 24- to 48-hour Holter monitor provides complete disclosure of rhythm disturbances, but only during a short window of time. They can also disclose symptoms that occur during recordings, directly by patient triggering or by written diary entries, allowing for rhythm-symptom correlation. If, however, a patient has intermittent symptoms, Holter monitor recordings, performed at a specific point in time, will be of no use. For example, if a patient has syncope and has a Holter recording that does not show any episodes of arrhythmia and the patient does not record an episode of syncope, the monitor is of no use. Furthermore, nonspecific arrhythmias such as atrial and ventricular premature complexes recorded in patients with serious symptoms such as syncope will have little, if any, meaning. For example, recording of a sinus pause in the middle of the night, which is likely vagally mediated, in a patient with syncope has neither specific meaning nor prognostic significance regarding the type of evaluation and management that needs to be performed. Furthermore, the information can be downloaded and sent transtelephonically to a monitoring center; this can be accomplished during symptoms or periodically in patients with previously defined severe arrhythmias. These monitors can act as real-time or endless loop recorders with memory capability and therefore can provide continuous monitoring and playback should a patient have a symptom that occurred minutes before the device was manually activated and marked. They can also be used intermittently and applied as required in patients with long- standing symptoms. They can provide ample leeway for a patient to apply and then remove the monitor so that the patient does not need to wear the device all the time. These small leadless devices are implanted or injected subcutaneously as a minor operation and provide real-time and endless loop recordings that are stored in the device for a period of up to 3 years. Stored data can be interrogated in the same way as pacemakers are interrogated, and the information can be printed. These devices are currently indicated for patients with occasional syncopal spells that are infrequent enough that they cannot be recorded on a Holter monitor or an external loop recorder. Specific criteria for such stored data must be programmed into these devices; otherwise they will not be recognized. In patients with exercise-induced arrhythmias, a treadmill test may be used to document the rhythm and assess effects of therapy; correlation with myocardial ischemia can also be made, although this is unusual. Finally, for athletes in whom extreme Chapter 11 Evaluation of the Patient with Suspected Arrhythmias 349 exertion is the only way to trigger an arrhythmia, monitors can be used during this type of exercise if it is deemed safe enough to measure and diagnose a rhythm disturbance that cannot be found any other way. Two or three fingertips placed on the carotid artery are important to make sure that a vagal reflex is initiated. The carotid sinus area should be massaged for about 5 seconds, beginning gently and progressing more rapidly to heavier pressure. Monitoring the patient for signs of cerebral hypoperfusion such as weakness, paresthesias, and numbness are important in avoiding transient ischemic attacks. The patient should be supine or even in a Trendelenburg position to maximize intravascular volume. Over the years, the indications and utility of electrophysiology studies have evolved, and many of the hoped-for predictive benefits of 350 Chapter 11 Evaluation of the Patient with Suspected Arrhythmias electrophysiologic testing have not turned out to be as useful as was initially thought.

The prevalence of the disease is 4 ally starts in the sixth to eighth decade of life; however cheap viagra capsules 100mg visa, cases cases per 100 order viagra capsules with visa,000 population cheap 100 mg viagra capsules with mastercard. A typical presenting The role of several exogenous toxins such as pesticides, symptom is memory impairment, and less frequently, the dis- formaldehyde, hexane, etc. Genetic defects have not been resembling that in Alzheimer’s disease develops through the mapped. Anterior horn involvement is seen in alpha-synuclein conformation and deposition of its insoluble some patients also. Accumulation of alpha-synuclein in oligoden- droglia may possibly be connected with increased level of its expression in glial cells, or with loss of such a function in oli- 14. The tau protein is linked with a microtubular apparatus sonism syndrome and autonomic dysfunction), striatonigral of neurons, and in the normal state proceeds polymerisation syndrome (the leading is a parkinsonism syndrome with mild of a monomeric tubulin during the folding of microtubules cerebellar and pyramidal signs), or by Shy-Drager syndrome of neuronal cytoskeleton, maintaining its stability. Impair- (the dominating sign is arterial orthostatic hypotension and ment of the tau protein conformation in taupathies leads to other autonomic signs caused by degeneration of brainstem down-regulation of its connections with microtubules, its reticular formation nuclei, with other groups of nuclei being release and aggregation, impairment of the cytoskeleton, and involved to a less extent). Widespread neuronal loss and gliosis of basal ganglia, brainstem, and cerebellar nuclei are observed (Rebeiz et al. It was frst described in 1963–1964 by Canadian phy- polyglutamine disorders with resembling clinical manifesta- sician J. It is supposed that the following factors tion of pons in a way of fattening of its anterolateral surfaces may infuence the progression of progressive supranuclear bilaterally and, along with atrophy of the middle cerebellar palsy with the “unfavourable tau haplotype”: nerve growth peduncles, which produce a fgure of a triangle or an isosceles factor and the excitotoxin glutamate, which increase the tau trapezium, with the apex facing the prepontine cistern. Such signal changes are not rylation; and carrier state of the ε4 allele of apolipoprotein-Е. The pseudobulbar syn- Neurodegenerative Disorders of the Central Nervous System 1079 Fig. Т2-weighted imaging (a–d) and proton density–weighted imag- pontine fbres is seen. Tere is a fattening of the anterior pontine ing (e): atrophy of pons, inferior olives, and cerebellar peduncles is surface on sagittal Т1-weighted imaging (f) seen with dilatation of basal cisterns. On Т2-weighted imaging, and drome and parkinsonism syndrome also develop with accom- tions of midbrain, especially of lamina tecti, is seen. Hypointense signal may be sive with prominent disability; the main sign leading to dis- seen on T2-weighted imaging in the lateral segments of globus ability is hypokinesia. Cavitation of tectum primary degenerative dementias; its prevalence in individu- and tegmentum of midbrain, striatum, and caudate nuclei als older than 60 years may reach 30 cases per 100,000. Tis cavitation cannot be diferentiated are such variants of the disease as pallido-nigral degeneration, from that seen in lacunar vascular encephalopathy. According to modern concepts, all these accumulation of several neuroflaments, which are concur- dementias are variants of the same disorder. Familial (30– rently linking with tubulin, and precipitation of abnormal 50%), and sporadic cases have been described. It is supposed protein inclusions in neurons, with further apoptotic death that the part of sporadic cases may be linked with the incom- of the latter by apoptotic mechanism. The frst signs of the disease usually manifest afer the age The disease starts at the ages of 50–70 years. Apathy, disinhibition, ment of complex sensations (discrimination sense, astereog- and the lack of spontaneous behaviour are typical features. The symptoms slowly expand on the second ipsi- Further signs include intellectual impairment, capacity to lateral and then on the contralateral extremities. Afer that, construe a motor program, motor aphasia, and acalculia man- akinetic rigid syndrome, dystonia, tremor, cortical myoclonus, ifest with social de-adaptation of a patient. Parkinsonism syndrome is ervation of memory and spatial orientation are the peculiar asymmetrical. In some patients pyramidal signs, oculomotor palsies, “alien hand” syndrome, frequently observed in the primarily amyotrophies, seizures, and incontinence are also seen. On microscopy, there is a large cortical signs: levodopa-resistant parkinsonism, alien hand syndrome, neurons loss, cortical spongiosis and gliosis, degeneration of apraxia or complex sensory loss, focal limb dystonia, severe basal ganglia, substantia nigra, dentate nuclei and cerebellar postural or kinetic tremor, and myoclonus. In 20% of cases, balloon-shaped cells are found Atrophy of the frontotemporal cortex, ofen asymmetrical, in the brain tissue, which are Pick bodies with tau-positive and signs of hydrocephalus due to cerebral atrophy are seen. Tau-protein aggregates are identifed in spaces in the frontoparietal–temporal regions due to atrophy the afected neurons and glia (Gibb et al. Tese fndings tal and the temporal lobes on the side contralateral to clini- are specifc. Famil- deposition of proteopolysaccaride complex (amyloid) in the ial cases have not been described. Several amyloidoses are genetically 4R conformer, which leads to increased afnity of the 4R-tau determined and caused by impairment of the amino acid protein to tubulin, and, hence, to slowing of the axonal trans- structure of proteins encoded by the mutant genes. It On autopsy, microscopy usually reveals difuse cerebral at- is several times more frequently observed in women, mani- rophy with predominant involvement of the parietal and the fests with progressive cognitive decline, and the frst and pre- occipital lobes. Acute psychotic episodes lular amyloid plaques with green fuorescence on confocal mi- may occur with delusions, hallucinations, and delirium. Hy- croscopy dyed with Congo red (beta-amyloid and a peptide perkinetic syndrome, parkinsonian syndrome, and seizures fragment of alpha-synuclein) and neurofbrillary tangles in are less frequently seen. Neuronal loss and destruction of sometimes the disease slowly progresses over 15–20 years and synapses with glial proliferation around the amyloid plaques terminates with total decline of personality, aphasia, and gen- are seen along with solitary or numerous Lewy bodies. Targeted study of temporal lobes complete penetrance of a mutant gene, and another gain a in coronal planes reveal asymmetrical atrophy of hippocampi Fig. Т2- weighted imaging at the level of uncal hippocampus (a,b) detects marked atrophy with thinning of cortex and the white mat- ter. The dilatation of the temporal horns of the lateral ventricles and the parahip- pocampal fssures are observed 1082 Chapter 14 with cortical thickening, dilatation of Bisha fssure bilater- gradient echo images, which are petechiae with haemoglobin ally and the temporal horns of the lateral ventricles (Scott et degradation product depositions. The disease of the parietal and the occipital lobes is also revealed with is characterised by amyloid deposits in the walls of small, usu- dilatation of their external subarachnoidal spaces. How- ever, solitary and large haemorrhages may be found, in par- ticular, deep-seated ones. Clinical picture is character- haemorrhages in cortical and subcortical regions without ob- ised by variable age of onset (17–80 years), by diferent neu- vious causes, and multiple hypointense areas revealed on Т2- rological symptoms (progressive dementia, spastic pareses, Fig. The disease ofen remains unrecognised dur- years of age), with an incubation period from 4 to 30 years. Diagnosis during lifetime is possible acute wave–slow wave (Kretzschmar 1996; Zuiev et al. Fatal familial insomnia is characterised by typical subarachnoidal and parenchymal haemorrhages are impairment of sleep–wake cycle and several autonomic signs, revealed. Relapsing course in young patients may raise sus- which indicates damage of reticular formation of the brain- picion of the correct diagnosis. Cerebral atrophy, vascular demyelination, habitants, and its nosological distinction is a subject of discus- and gliosis are seen. The prion protein was inoculated in cases of this disease, which may also be familial or sporadic. The group of primary cerebral amyloidoses characterised by Kuru, the frst prion disease described in humans, was dis- deposits of amyloid in brain parenchyma, with abnormal prion covered in Papua New Guinea native inhabitants, who con- Sc protein PrP being one of the main components of deposits. Due to eradication of cannibalism, it is Several prion diseases in animals are known: scrapie in sheep, not found at present. The prevalence of relatively recently described human spheres, decrease of brain volume and weight are seen.

Prompt small children 100mg viagra capsules visa, and those with with bloody order viagra capsules 100 mg, dysenteric replacement and maintenance of water and electrolyte bal- stools viagra capsules 100mg low price, and in Clostridium difficile infection), are the main- ance with i. A single stays of therapy in such cases (see Oral rehydration ther- dose of doxycycline, given early, significantly reduces the apy, p. Some specific intestinal infections do amount and duration of diarrhoea and eliminates the or- benefit from chemotherapy: ganism from the faeces (thus lessening the contamination of the environment). Clarithromycin, azithromycin or mycin or azithromycin) are alternatives for resistant organ- ciprofloxacin by mouth eliminates the organism from the isms. Oral zinc acetate supplements have been shown stools but is only clinically effective if commenced within modestly to reduce the volume and duration of cholera diar- the first 24–48 h of the illness and if is the patient is severely rhoea in combination with antibiotics, probably by improv- affected. Ciprofloxacin resistance has become common in ing gut mucosal integrity and function in malnourished parts of the world (e. Give an antimicrobial for severe salmonella amines) in the intestine leads to cerebral symptoms and gastroenteritis, or for bacteraemia or salmonella enteritis even to coma. The This is most commonly seen in young women with normal commonest regimen involves combinations of topical urinary tracts. Antibiotic treatment shortens the duration of non-absorbable (framycetin, colistin, nystatin and ampho- symptoms but may cause adverse reactions, and 20–30% are tericin) and i. Ini- number of Gram-negative bacilli and yeasts while main- tial treatment with co-amoxiclav, an oral cephalosporin (e. Current the topical agents alone, or administering oral ciprofloxa- resistance rates of 20–50% among common pathogens for cin. Selective decontamination should be used with great trimethoprim and amoxicillin threaten their value for em- care in hospitals with a high incidence of multiply resistant pirical therapy in many parts of the world. Peritonitis is usually a mixed infection and antimicrobial choice must take account of coliforms and anaerobes, although the need to include cover for the other major Upper urinary tract infection component of the bowel flora, streptococci, is less certain. Acute pyelonephritis may be accompanied by septicaemia Piperacillin-tazobactam or a combination of gentamicin, and is usually marked by fever and loin pain. In such pa- benzylpenicillin plus metronidazole, or meropenem alone tients it is advisable to start with co-amoxiclav i. This is an infection of the biotics (5–7 days) are associated with a good outcome for kidney substance and so needs adequate blood as well as intestinal perforations that are surgically corrected within a urine concentrations, although a switch to an oral agent day or two. Surgical drainage of peritoneal collections and (guided by the results of susceptibility testing) to complete abscesses may need to be repeated. Antibiotic-associated colitis and Clostridium difficile Upper or lower tract infection with extended-spectrum diarrhoea. Such bacteria are usually resistant also to ciprofloxacin, parenteral cephalosporins and genta- micin. Attacks with a longer interval between them and Patients with abnormal urinary tracts, e. Identification of the causative should overcome most recurrent infections but, if these fail, organism and of its sensitivity to drugs is important 7–14 days of high-dose treatment may be given, following because of the range of organisms and the prevalence of which continuous low-dose prophylaxis may be needed resistant strains. There is some evidence that daily ingestion of cranberry be effective, as many antimicrobials are concentrated in juice may reduce the frequency of relapse in women, per- the urine. Infections of the substance of the kidney require haps by sugars within the juice interfering with adhesion the doses needed for any systemic infection. Vesicoureteric reflux 199 Section | 3 | Infection and inflammation (passage of bladder urine back up the ureter to the kidney) it has retained activity against a useful proportion of accounts for about a third of urinary tract infections in chil- urinary tract coliforms that have acquired resistance to dren, and causes progressive renal damage. It is well antibiotic prophylaxis in such patients is modestly effective absorbed from the gastrointestinal tract and is concentrated at reducing symptomatic infections. Excretion is reduced when there is renal insufficiency, rendering the drug both Asymptomatic infection (‘asymptomatic more toxic and less effective. Adverse effects include nausea bacteriuria’) and vomiting (much reduced with the macrocrystalline This may be found by routine urine testing of pregnant preparation) and diarrhoea. Peripheral neuropathy occurs women or patients with known structural abnormalities especially in patients with significant renal impairment, in of the urinary tract. Appropriate anti- include rashes, generalised urticaria and pulmonary infil- microbial therapy should be given, chosen on the basis of tration with lung consolidation or pleural effusion. Amoxicil- furantoin is safe in pregnancy, except near to term (because lin or a cephalosporin is preferred in pregnancy, although it may cause neonatal haemolysis), and it must be avoided nitrofurantoin may be used if imminent delivery is not in patients with glucose-6-phosphate dehydrogenase likely (see below). Response to a single, short course is often good, but recur- rence is common and a patient can be regarded as cured A general account of orthodox literature is given below, but only if he has been symptom-free without resort to antimi- treatment is increasingly the prerogative of specialists, who, crobials for a year. Four weeks of oral therapy is often given as is so often the case, get the best results. Tracing and screening of contacts plays a vital part in controlling spread and reduc- Chemoprophylaxis ing re-infection. Recommended treatment regimens vary Chemoprophylaxis is sometimes undertaken in patients to some extent among countries, and this is in response liable to recurrent attacks or acute exacerbations of inerad- to differences in antimicrobial susceptibility of the relevant icable infection. It may prevent progressive renal damage in pathogens and availability of antimicrobial agents. The drugs are best given as a single oral The problems of b-lactam and quinolone resistance in Neis- dose at night. England and Wales, reaching over 60% in ethnic white pa- tients in 2009), and selection of a particular drug will de- pend on sensitivity testing and a knowledge of resistance Special drugs for urinary patterns in different locations. Cefixime and ceftriaxone re- sistanceon testing in vitro are increasing, but not yet tolevels tract infections that compromise therapeutic efficacy. Effective treatment re- General antimicrobials used for urinary tract infections are quires exposure of the organism briefly to a high concentra- described elsewhere. Single-dose regimens are practicable and tion of the urinary tract: improve compliance. The following schedules are effective: Nitrofurantoin, a synthetic antimicrobial, is active Uncomplicated anogenital infections. High-dose cefix- against the majority of urinary pathogens except pseudo- ime 400 mg by mouth; spectinomycin i. Presenting as pyrexia, it is common during the few hours ceftriaxone is recommended. Chlamydia trachomatis is frequently tachycardia, headache, myalgia and malaise, which last present with Neisseria gonorrhoeae; tetracycline by mouth for up to a day. It cannot be avoided by giving graduated for 7 days or a single oral dose of azithromycin 1 g or oflox- doses of penicillin. Prednisolone may prevent it and should acin 400 mg will treat the chlamydial urethritis. Non-gonococcal urethritis Chancroid The vast majority of cases of urethritis with pus in which gonococci cannot be identified are due to sexually transmit- The causal agent, Haemophilus ducreyi, normally responds ted organisms, usually Chlamydia trachomatis (the most to erythromycin for 7 days or a single dose of ceftriaxone common bacterial sexually-transmitted infectionworldwide) or azithromycin. Granuloma inguinale Pelvic inflammatory disease Calymmatobacterium granulomatis infection responds to co- trimoxazole or doxycycline for 2 weeks or a single dose of Several pathogens are usually involved, including Chla- azithromycin weekly for 4 weeks. A combination of antimi- Bacterial vaginosis (bacterial crobials is usually required, e. The condition is associated with over- growth of several normal commensals of the vagina includ- Primary and secondary syphilis are effectively treated by a sin- ing Gardnerella vaginalis, Gram-negative curved bacilli and gle dose of 2. Doxycycline or erythromycin orally for 2 weeks may characteristic fishy odour of the vaginal discharge. The con- be used for penicillin-allergic patients, and a single oral dition responds well to a single dose of metronidazole 2 g dose of 2 g azithromycin appears to have equivalent effi- or 400 mg thrice daily for a week by mouth, with 7 days of cacy.

Moreover viagra capsules 100mg with visa, in vitro Azithromycin A studies show only intermediate effcacy for ciprofoxacin order viagra capsules without prescription. Prospective randomized double blind placebo-controlled Cat-scratch disease of the head and neck in a pediatric evaluation of azithromycin for treatment of cat-scratch population: surgical indications and outcomes order viagra capsules with a visa. Seven of 14 azithromycin-treated patients (500 mg on day 1, In children, failure of medical therapy in cases that presented followed by 250 mg on days 2–5) showed an 80% reduction in as persistent lymphadenopathy often were accompanied by vio- initial lymph node volume compared to one of 15 placebo- laceous skin changes, extreme tenderness to palpation, and even treated controls during the frst 30 days of observation. Surgical intervention C Cat scratch disease, bacillary angiomatosis, and other infections due to Rochalimaea. Hexsel  Physical examination: patient in standing position with relaxed gluteus muscles. A new photonumeric severity quantitative and qualitative scale was developed and validated; fve key morphological aspects of cellulite were identifed for comparison. Side-by-side comparison of areas with and without cel- lulite depressions using magnetic resonance imaging. Cellulite consists of surface relief alterations resulting in depres- Thirty female patients with cellulite depressions on the but- sions and raised areas and thus irregular appearance, such as tocks had underlying fbrous septa, which were thicker, ramifed an orange peel, cottage cheese or mattress-like appearance of and perpendicular to the skin surface. Women are most frequently affected by this condition;  Laser, light sources B this is due to the structure and anatomy of the subcutaneous  Radiofrequency devices B septa compared to the structure of men. In addition, cellulite is aggravated by progressive skin laxity or faccidity, localized Subcision: a treatment for cellulite. Subcision: uma alternativa cirúrgica para a lipodistrofa ginóide (‘celulite’) e outras alterações do relevo corpo- ral. Based on clinical assessment of pre- and post-treatment stan- Specifc treatments: dardized photographs on 232 patients, subcision was shown to  Subcision, which treats the subcutaneous septae that pulls the be effcacious in the treatment of high-grade cellulite. Aesthet Surg J 2011; 31: Clinical improvement scores of photographs were made inde- 328–41. Circumferential thigh ment with a 1440 nm pulsed laser delivered through a cannula. Subjective physician evaluations indicated improve- A prospective clinical study to evaluate the effcacy and ment in the appearance of cellulite. Journal of were treated with the VelaSmooth device with eight to 16 treat- Drugs in Dermatology; in press. Based on physician assessment using pre- Fifteen women with cellulite were treated with 1440 nm pulsed and post-treatment photographs, all patients showed some level laser with side fring fber. There was improvement in cellulite in of improvement in skin texture and cellulite. The mean decrease 68% of subjects on photographic evaluation by two independent in thigh circumference was 0. J Eur Acad Dermatol Venereol 2012; 26: appearance of cellulite with dual-wavelength, low-level laser 696–703. The treatment began with 110 J/cm2, a device comprising a low-level, dual-wavelength diode laser increased by 10–20 J/cm2 in subsequent procedures. Cellulite was (650 nm and 915 nm, to target fat), combined with heat induc- reduced in 89. In the placebo group, no one leg, with the untreated contralateral thigh serving as a statistically signifcant changes were observed. Twelve weekly sessions were clinical study to determine the effcacy of the VelaSmooth given for 12 minutes on each buttock, with the treatment end- system versus the Triactive system for the treatment of cel- point of 42°C external skin temperature. Velasmooth™ combines infrared light (680– Unipolar radiofrequency treatment to improve the appear- 1550 nm) with bipolar radiofrequency and mechanical massage by vacuum suction. There was a perceived treatments (number of treatments at the investigator’s discretion and resulted in a mean of 4. There was no statistically signifcant untreated side of the thigh served as control. All participants Cellulite treatment using a novel combination radio- responded to treatment. The blinded evaluations of photographs frequency, infrared light, and mechanical tissue manipula- using the cellulite grading scale demonstrated the following tion device. J Cosmet Laser Ther 2005; 7: improvements in mean grading scores for the treated leg versus 81–5. Evaluation of the effects of caffeine in the microcircula- Addition of conjugated linoleic acid to a herbal anticel- tion and edema on thighs and buttocks using the orthogo- lulite pill. J Cosmet ment in visible cellulite in 75% of subjects that received herbal Dermatol 2007; 6: 102–7. At the end of 3 months, eight out of nine thighs treated A two-center, double blinded, randomized trial testing with the combination were downgraded to a lower cellulite the tolerability and effcacy of a novel therapeutic agent for grade by clinical examination, digital photography, and pinch cellulite reduction. The average measured decrease in thigh circumference domized, controlled trial of two therapies, endermologie was 1. Discussion gists noted greater improvement in the treated group in 68% of 1115–17. This randomized, controlled trial assessed the effcacy of ami- Topical retinol improves cellulite. Immunocompromised patients, those with signs of systemic toxicity, and otherwise debilitated patients should be treated as inpatients with intravenous antimicrobials (e. If there is evidence of head and neck disease or sinus infection, amoxicillin combined with clavulanic acid should be considered to cover H. Sites of entry for infection should be sought, such as excoria- tions in eczema or following trauma, and these should be treated. Swabs of wounds and broken skin may be helpful, but surface swabs of unbroken skin provide little or no useful information. If available, aspirate of bullae may Cellulitis is strictly an acute, subacute, or chronic infection of yield positive cultures. Slightly better rates for isolation than the subcutaneous tissues, whereas erysipelas is an infection of those of needle aspirates have been achieved with punch skin the dermis and superfcial subcutis. Crepitus should prompt the clinician to the ciitis may occur rarely, usually in relation to immunosuppres- presence of either clostridia or non-spore-forming anaerobes, sion or atypical organisms. These are rare, but necrotizing either alone or mixed with other bacteria such as Pseudomonas, fasciitis may have a mortality of up to 50%. Penicillin G with fucloxacillin B Any underlying and predisposing condition should be identifed Penicillin V B and treated to prevent subsequent recurrence. Perhaps the com- Amoxicillin with clavulanic acid B monest condition that is not identifed and treated is toe web Ceftriaxone A tinea pedis, which provides a portal of entry for infection. Roxithromycin B Uncomplicated cellulitis and erysipelas may be managed without admission if the patient does not exhibit signs of sys- The course, costs and complications of oral versus intra- temic toxicity. In such cases oral broad­spectrum antibiotics, chosen venous penicillin therapy of erysipelas. Infection 1984; fcient, supplemented with a single parenteral loading dose or 12: 390–4.